Tell us how to reach you and a member of our team will call you to walk through the rest. There is nothing to sign here, no documents to upload, and no obligation of any kind.
All fields marked with an asterisk are required. We will not ask for income details, insurance cards, or a signature on this form — those are handled during the call, once you have had a chance to ask questions.
Prefer to do this by phone? Call 817-973-7406 at any hour and we will take your details and start the same process.
Your details go straight to our Care Relief team. Nothing is posted and nothing waits in a queue overnight.
A member of our team calls to explain the program, answer questions, and go through the financial section with you.
Only after that conversation is there anything to sign, and only if you want to continue. Nothing is committed before then.
Once approved, the reduction is applied to your account. You will be told exactly what you owe before anything is due.
No. You can apply before a visit, during one, or after a bill has arrived. Applying ahead of time simply means the discount is already in place if you ever need us.
Not in any way. Emergency care is provided based on your medical need, never on your ability to pay or on whether you have applied. This is a billing program and it is kept entirely separate from your treatment.
Because most people would rather discuss it with a person than type it into a web page, and because it lets you ask questions first. We only need enough here to reach you. The financial details are covered on the call.
No. The program is open to insured and uninsured patients alike. If you do have insurance, it is worth mentioning on the call, because it can change how much of the balance the program applies to.
The form takes about two minutes. Our team aims to call you within one to two business days, and the conversation itself usually takes ten to fifteen minutes.
Yes. Your details go only to our Care Relief team and are used solely to assess this application. Our Privacy Policy sets out how we handle and protect your information.
Not sure whether you qualify? Our Financial Support and Care Relief Program page has an estimator that gives you an answer in seconds. For how emergency charges work generally, see our Billing Disclosure.
*Demonstrated financial standing required for financial assistance. Submitting this form does not guarantee qualification; final approval is based on your completed application.